Aim: Most brachial plexus palsies occur following high-velocity trauma. The shoulder joint is a large proximal joint which influences the motion of the hand. Transfer of the trapezius muscle is an effective alternative for palsy of the deltoid and supraspinatus muscles. Methods: Between 2009 and... Read more

Aim: Most brachial plexus palsies occur following high-velocity trauma. The shoulder joint is a large proximal joint which influences the motion of the hand. Transfer of the trapezius muscle is an effective alternative for palsy of the deltoid and supraspinatus muscles. Methods: Between 2009 and 2014, 32 patients were treated with modified trapezius muscle transfer in which only the descending fibers along with their attachment to the lateral third of clavicle were used. The clavicle was fixed to the anterolateral surface of the humerus by cancellous screws. The arm was immobilized for 6 weeks. Results: All the 32 patients had improved function with stability of the shoulder. The average increase in active abduction was from 7.5° (range: 0°-30°) to 85° (range: 45°-140°), and the mean forward flexion increased from 5.63° (range: 0°-15°) to 55.2° (range: 40°-90°) after a mean follow‑up of 8.25 months. Twenty‑four of the 32 patients rated the result as good to excellent and were satisfied with the improvement in stability and function. Fifty nine point thirty eight percent patients had Medical Research Council Muscle power 4 after the surgery. Conclusion: Transfer of the upper trapezius muscle with a segment of the clavicle segment for a flail shoulder can provide satisfactory function and stability with fewer complications. Back

Aim: Mesenchymal stem cells (MSCs) are an excellent potential source of cells for bone tissue engineering due to their excellent renewal ability and osteogenic differentiation capabilities. This study was designed to evaluate the bone formation properties of a demineralized cancellous bone... Read more

Aim: Mesenchymal stem cells (MSCs) are an excellent potential source of cells for bone tissue engineering due to their excellent renewal ability and osteogenic differentiation capabilities. This study was designed to evaluate the bone formation properties of a demineralized cancellous bone scaffold seeded with MSCs, with or without periosteum, in a critical size bone defect model in rabbits. Methods: Rabbit culture‑expanded bone marrow (BM)‑MSCs were seeded onto a human demineralized cancellous bone (HDCB) scaffold. Bone defects measuring 15 mm in length were created in each radius. A total of 56 bone defects in 28 rabbits were randomly assigned to one of the 4 groups for scaffold implantation: Group 1: HDCB graft only; Group 2: periosteum‑wrapped HDCB graft; Group 3: HDCB graft seeded with BM‑MSCs and Group 4: periosteum‑wrapped HDCB graft seeded with BM‑MSCs. All rabbits were sacrificed 12 weeks after surgery for gross observation, radiological assessment, histological analyses and biomechanical measurements. Results: New bone (NB) formation and bone healing were successfully achieved, both radiologically and histologically, on demineralized cancellous bone graft seeded with BM‑MSCs. Results were improved when BM‑MSCs were associated with periosteum. Conclusion: This study demonstrates that repair of bone defects in a rabbit model can be achieved through bone grafting using BM‑MSCs, implanted on a demineralized cancellous bone scaffold. The formation of NB was optimized when combined with the preservation of periosteum at the site of injury. Back

Hyperbaric oxygen (HBO) treatment has been widely used in clinical work, while, hydrogen-rich saline (HRS) has also been shown its protective effect of ameliorating ischemia/reperfusion (IR) injury. What will we obtain if these two approaches combined together? In this study, we set five... Read more

Hyperbaric oxygen (HBO) treatment has been widely used in clinical work, while, hydrogen-rich saline (HRS) has also been shown its protective effect of ameliorating ischemia/reperfusion (IR) injury. What will we obtain if these two approaches combined together? In this study, we set five independent groups (Sham, IR, HBO, HRS and HBO+HRS) of rat abdominal skin flap IR model with different interferences. In conclusion, the synergistic application of HBO and HRS showed a higher flap survival rate, which could be a combined treatment to improve skin flap survival against IR injury. Back

Rhinoplasty surgery remains one of the most difficult operations of the face. Improving aesthetic appearance and maintaining nasal function are inseparable goals in rhinoplasty surgery, and failure to achieve either of these objectives can be devastating for the patient. After evaluating a... Read more

Rhinoplasty surgery remains one of the most difficult operations of the face. Improving aesthetic appearance and maintaining nasal function are inseparable goals in rhinoplasty surgery, and failure to achieve either of these objectives can be devastating for the patient. After evaluating a variety of rhinoplasty complications, increased attention was devoted to the surgical technique for reconstruction of the dorsal aesthetic lines and nasal tip projection in the patient with a prominent dorsal hump. Based on the modern concept of cartilage conservation, the autospreader flap rotation technique should be considered when dorsal reduction is required. Autospreader flaps are a useful tool in the prevention of postoperative nasal obstruction, segmental (inverted V) appearance, midfacial axial asymmetry and an overdone supratip break. In addition, they assist in preserving ethnicity of the nose when desired. The patient with a long nose, prominent dorsal hump, short nasal bones and low lower lateral cartilages are considered to be an ideal candidate for an autospreader flap. Back

Aim: To report the 1st year experience of the skin bank opened at the Evangelical University Hospital of Curitiba (HUEC), Brazil in June 2013. Methods: A retrospective statistical and epidemiological study was conducted from data obtained from the activities of the HUEC skin bank from June 2013... Read more

Aim: To report the 1st year experience of the skin bank opened at the Evangelical University Hospital of Curitiba (HUEC), Brazil in June 2013. Methods: A retrospective statistical and epidemiological study was conducted from data obtained from the activities of the HUEC skin bank from June 2013 to August 2014. Results: The HUEC skin bank harvested tissue from 45 cadaveric donors (46.6% female and 53.3% male), with an average age of 36.42. The white skin‑colored donors represented 91% of donations. Most causes of death were of neurological origin (55.6%). Eighty‑one batches were harvested. The bank processed 31,314.63 cm² of skin for transplantation (41 batches), and 38 batches were discarded. The distributed allografts totaled 28,940.82 cm², with tissue from a single donor benefitting up to 5 patients. A total of 52 transplant procedures were performed (66.6% of recipients were male and 33.3% female), burn victims represented 83.3% of the recipients. Conclusion: The HUEC skin bank provides skin primarily for victims with severe third‑degree burns, mostly men, and who are treated and transplanted in the HUEC as a result of high demand. The successful outcomes highlight the potential use for other clinical indications. Back

Rhinosporidiosis is caused by the organism Rhinosporidium seeberi. It is a rare aquatic protistan parasite. Though more prevalent in Asiatic regions, cases have also been reported in European countries. In India, it mostly affects the southern part. Rhinosporidium seeberi most commonly affects... Read more

Rhinosporidiosis is caused by the organism Rhinosporidium seeberi. It is a rare aquatic protistan parasite. Though more prevalent in Asiatic regions, cases have also been reported in European countries. In India, it mostly affects the southern part. Rhinosporidium seeberi most commonly affects the mucous membranes, but can also affect other structures including the larynx, trachea, skin, genitalia, lungs and rectum. The typical presentation is that of a pinkish mass which bleeds profusely. Isolated lacrimal sac rhinosporidiosis is very rare. Computed tomography scans and magnetic resonance imaging are helpful in diagnosis, but histopathological study along with Gomori methenamine silver, periodic acid‑Schiff, and potassium chloride are required for confirmation. Its mainstay of treatment is surgery. Prognosis is excellent, but recurrence is not unusual. Back

Autologous breast reconstruction with perforators has been previously avoided in tissues that have undergone liposuction. We present a case series and literature review of breast reconstruction with deep inferior epigastric perforator (DIEP) flaps after abdominal wall liposuction. An MEDLINE... Read more

Autologous breast reconstruction with perforators has been previously avoided in tissues that have undergone liposuction. We present a case series and literature review of breast reconstruction with deep inferior epigastric perforator (DIEP) flaps after abdominal wall liposuction. An MEDLINE search was performed for all relevant articles describing breast reconstruction with DIEP flap technique following the abdominal wall liposuction. Key search words used included “DIEP”, “DIEAP”, “deep inferior epigastric perforator”, “liposuction” and “free flap”. All published data on the topic from 1965 to December 2014 were reviewed. Articles were assessed for reports of clinical cases, complications, age, liposuction amount, time since liposuction and number of perforators for comparison. We have also presented 2 patients who underwent a DIEP procedure with a previous history of liposuction. Eight cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the literature in addition to the presented cases. The preoperative and postoperative course was uneventful in all cases except one patient who had a mild cellulitis managed with antibiotics and a second patient with a drainable hematoma. The average age was 52 years ± 6.4 years old, one perforator was used in all cases except one where 2 were used, and the average amount of total liposuction was 1,084 mL. No major complications were reported. Previous liposuction is not an absolute contraindication for free‑flap breast reconstruction. Preoperative management should include evaluation of suitable perforators by duplex ultrasound or computed tomography angiography. Larger case series are needed to better understand the safety of perforator flaps after liposuction. Back

Aim: Permanent expanders allow for breast reconstruction as a single stage. These prostheses are more expensive than conventional tissue expanders, but this excess cost is markedly offset as only one operation is required. However, if the revision rate is sufficiently high, then this effect is... Read more

Aim: Permanent expanders allow for breast reconstruction as a single stage. These prostheses are more expensive than conventional tissue expanders, but this excess cost is markedly offset as only one operation is required. However, if the revision rate is sufficiently high, then this effect is negated. We aim to compare costs of one-stage vs. two-stage reconstruction at a single center, taking into account explantation and unexpected admissions following complications. Methods: A retrospective review was carried out on all patients who underwent one‑stage and two‑stage reconstruction over a 5‑year period by a single surgeon. A cost analysis was performed taking into account, explantation and additional admissions. Results: One hundred and forty-three one‑stage and 45 two‑stage procedures were included. The explantation rate for one‑stage procedures is 36%, at a mean of 12.9 months postimplantation, the majority of which were exchanged for silicone implants to improve cosmesis. Four (9%) of the two‑stage procedures were explanted a mean of 18 months postreconstruction. Overall, one‑stage reconstructions were significantly more expensive than the two‑stage group (P = 0.016). Conclusion: There are many benefits of one‑stage breast reconstruction. However, it does not appear to be cost‑effective when additional admissions for explantation surgery are taken into account. Back

Injuries to the hand secondary to high pressure paint guns are considered to be true hand emergencies. These rare injuries may have serious outcomes, and a critical step in their management is extensive debridement performed within the first six hours following injury. For this reason, their... Read more

Injuries to the hand secondary to high pressure paint guns are considered to be true hand emergencies. These rare injuries may have serious outcomes, and a critical step in their management is extensive debridement performed within the first six hours following injury. For this reason, their diagnosis should not be delayed, and the hand surgeon should be informed immediately to initiate appropriate treatment. In this report, the authors describe a patient who was injured with a chemical paint gun, and whose injury was not diagnosed in the emergency department. The patient subsequently developed tenosynovitis. His treatment is reported herein. Back

Aim: The aim was to study the role of jet force technology (JFT) in wound management. Methods: This is a retrospective analysis of 18 cases of chronic nonhealing wounds in which JFT was used. Chronic wounds which had already undergone surgical debridement but which were not ready for... Read more

Aim: The aim was to study the role of jet force technology (JFT) in wound management. Methods: This is a retrospective analysis of 18 cases of chronic nonhealing wounds in which JFT was used. Chronic wounds which had already undergone surgical debridement but which were not ready for reconstruction (skin graft/flap) secondary to a persistent bacterial load or infection (tissue culture positive) were included in the study. Patients were divided into two groups. Group 1 included those patients who were poor candidates for anesthesia or who refused for reconstruction and were managed with JFT only. Group 2 included those patients who were cleared for anesthesia and who were and who were managed with JFT and skin graft or flap coverage. The time to negative wound cultures after JFT and the total duration of healing were noted. Results: In both the groups, all tissue culture positive chronic wounds became negative after 2 ± 1 weeks and were ready for reconstruction. In Group 1 (6 patients), the wounds completely healed in 5‑6 weeks with JFT only. In Group 2 (12 patients), the wounds completely healed in 3‑4 weeks with JFT and skin graft/flap. Conclusion: Hydrotherapy with JFT helps in the removal of contaminants, debris, and microbial colonization of the wound leading to spontaneous wound healing and facilitating wound bed preparation for wound coverage by a skin graft or flap. Back

Aim: Negative pressure wound therapy (NPWT) has achieved widespread success in the treatment of chronic wounds. However, its effects have been only partially explored, and investigations have generally concentrated on the wound-dressing interface; a detailed histopathological description of the... Read more

Aim: Negative pressure wound therapy (NPWT) has achieved widespread success in the treatment of chronic wounds. However, its effects have been only partially explored, and investigations have generally concentrated on the wound-dressing interface; a detailed histopathological description of the evolution of wounds under NPWT is still lacking. The present study was performed to investigate the effect of a limited access dressing (LAD) which exerts intermittent NPWT in a moist environment on chronic wounds. Methods: A total of 140 patients were randomized into 2 groups: LAD group (n = 64) and conventional dressing group (n = 76). By histopathological analysis of the granulation tissue, the amount of inflammatory infiltrate, necrotic tissue, angiogenesis, and extracellular matrix (ECM) deposition was studied and compared to determine healing between the 2 groups. Results: After 10 days of treatment, histopathological analysis showed a significant decrease in necrotic tissue with LAD compared to the conventional dressing group (mean ± standard error, 11.5 ± 0.48 vs. 10.1 ± 0.30, P = 0.007), the number of inflammatory cells (12.6 ± 0.60 vs. 8.63 ± 0.35, P = 0.018), a significant increase in new blood vessels (12.8 ± 0.58 vs. 9.3 ± 0.29, P = 0.005) and ECM deposit (13.3 ± 0.50 vs. 9.6 ± 0.24, P = 0.001). Conclusion: LAD exerts its beneficial effects on chronic wound healing by decreasing the amount of necrotic tissue and inflammatory cells while increasing the amount of ECM deposition and angiogenesis. Back

Aim: Emerging evidence favors the important role of antioxidants, matrix metalloproteinases (MMPs), and nitric oxide (NO) in the healing of diabetic wounds. There is a lack of substantial evidence regarding the effects of negative pressure on antioxidants, MMPs and NO in chronic wounds associated... Read more

Aim: This paper addresses the assessment of the composition of a general wound, in terms of all identifiable categories of tissue and pigmentation in an attempt to improve accuracy in assessing and monitoring wound health. Materials and Methods: A knowledgebase of clusters was built into the hue,... Read more

Aim: This paper addresses the assessment of the composition of a general wound, in terms of all identifiable categories of tissue and pigmentation in an attempt to improve accuracy in assessing and monitoring wound health. Materials and Methods: A knowledgebase of clusters was built into the hue, saturation and intensity (HSI) color space and then used for assessing wound composition. Based on the observation that the clusters are fairly distinct, two different algorithms, that is, Mahalanobis distance (MD) based and the rotated coordinate system (RCS) method, were used for classification. These methods exploit the shape, spread, and orientation of each cluster. Results: The clusters in the HSI color space, built from about 9,000 (calibrated) pixels from 48 images of various wound beds, showed 8 fairly distinct regions. The inter‑cluster distances were consistent with the visual appearance. The efficacy of the MD and RCS based methods in 120 experiments taken from a set of 15 test images (in terms of average percent‑match) was found to be 91.55 and 93.71, respectively. Conclusion: Our investigations established eight categories of tissue and pigmentation in wound beds. These findings help to determine the stage of wound healing more accurately and comprehensively than typically permitted through use of the 4‑color model reported in the literature for addressing specific wound types. Back

Aim: Changes in the pH of chronic wounds can inhibit the optimal activity of various enzymes in the wound environment, thereby delaying wound healing. The aim of the present study is to monitor the effect of limited access dressing (LAD) on the pH on the surface of chronic wounds. Methods: A... Read more

Aim: Changes in the pH of chronic wounds can inhibit the optimal activity of various enzymes in the wound environment, thereby delaying wound healing. The aim of the present study is to monitor the effect of limited access dressing (LAD) on the pH on the surface of chronic wounds. Methods: A total of 140 patients with chronic wounds of more than 4 weeks duration were divided into two groups by simple randomization: a LAD group (n = 64) and a conventional dressing group (n = 76). Fifty‑six participants (22 in the LAD group and 34 in the conventional dressing group) were lost to follow‑up or withdrawn from the study. Results: In the LAD group (n = 42), the mean age was 38.3 ± 10.56 years (range: 12‑60 years), and the mean wound size at the time of admission was 28 cm2 (range: 19‑40 cm2). In the conventional dressing group (n = 42), the mean age was 35.3 ± 14.0 years (range: 17‑65 years), and the mean wound size at the time of admission was 26 cm2 (range: 18‑39 cm2). Patients treated with LAD showed a significant decrease in the mean ± standard deviation pH when compared with the conventional dressing group (0.83 ± 0.52 vs. 0.41 ± 0.26, P = 0.048). Conclusion: LAD reduces the chronic wound surface pH to a level required for the optimal function of various enzymes. This could be a factor that exerts a beneficial effect on wound healing. Back

Wound healing requires a complex interaction and coordination of different cells and molecules. Any alteration in these highly coordinated events can lead to either delayed or excessive healing. This review provides an overview of adult wound healing physiology. A review of the literature focused... Read more

Wound healing requires a complex interaction and coordination of different cells and molecules. Any alteration in these highly coordinated events can lead to either delayed or excessive healing. This review provides an overview of adult wound healing physiology. A review of the literature focused on wound healing physiology and current advances in wound healing was conducted using the online MEDLINE/PubMed database. The aim of this review was to inspire further investigation into wound healing physiology that will ultimately translate into improved patient care. Back

Angiogenesis plays a crucial role in wound healing by forming new blood vessels from preexisting vessels by invading the wound clot and organizing into a microvascular network throughout the granulation tissue. This dynamic process is highly regulated by signals from both serum and the... Read more

Angiogenesis plays a crucial role in wound healing by forming new blood vessels from preexisting vessels by invading the wound clot and organizing into a microvascular network throughout the granulation tissue. This dynamic process is highly regulated by signals from both serum and the surrounding extracellular matrix environment. Vascular endothelial growth factor, angiopoietin, fibroblast growth factor and transforming growth factor-beta are among the potent angiogenic cytokines in wound angiogenesis. Specific endothelial cell ECM receptors are critical for morphogenetic changes in blood vessels during wound repair. In particular integrin (αvβ3) receptors for fibrin and fibronectin, appear to be required for wound angiogenesis: αvβ3 is focally expressed at the tips of angiogenic capillary sprouts invading the wound clot, and any functional inhibitors of αvβ3 such as monoclonal antibodies, cyclic RGD peptide antagonists, and peptidomimetics rapidly inhibit granulation tissue formation. In spite of clear knowledge about influence of many angiogenic factors on wound healing, little progress has been made in defining the source of these factors, the regulatory events involved in wound angiogenesis and in the clinical use of angiogenic stimulants to promote repair. Back

The dynamic process of wound healing has various phases, and the knowledge of which is essential for identification of the pathology involved in a chronic intractable wound. Various instruments for the assessment of wound healing have been described, primarily for clinical assessment of the... Read more

The dynamic process of wound healing has various phases, and the knowledge of which is essential for identification of the pathology involved in a chronic intractable wound. Various instruments for the assessment of wound healing have been described, primarily for clinical assessment of the wound. However, very few instruments are currently available for histological grading of the wound. The aim of this article is to review all available literature from 1993 to 2014 on the objective histological scoring of the state of wound healing. This review article emphasizes the importance of histological grading of wounds based on the different parameters from each phase of wound healing and the need for an ideal grading system in order to help assessment of wound status. The parameter chosen in an experimental model should be defined by the scientific question, the underlying hypothesis and the pathogenesis of the disease. Back

Cysts of the jaw present as swellings of jaws and midface. Of the different varieties, the dentigerous cyst is the most common type of noninflammatory odontogenic cyst and the frequent cause of a lytic lesion associated with an impacted tooth. The cyst develops from epithelial remnants of the... Read more

Cysts of the jaw present as swellings of jaws and midface. Of the different varieties, the dentigerous cyst is the most common type of noninflammatory odontogenic cyst and the frequent cause of a lytic lesion associated with an impacted tooth. The cyst develops from epithelial remnants of the tooth forming organ. The obstruction of venous flow due to compression of tooth follicle by developing tooth causes fluid accumulation between the follicular epithelium and the crown of the developing or unerupted tooth resulting in a cyst. Most small dentigerous cysts manifest in early age, usually as an incidental discovery in radiographic examinations. However, they can grow extremely large, asymptomatically, and remain undetected until they enlarge enough, causing bony expansion and asymptomatic facial swelling. We present a challenging case of massive dentigerous cyst in a 13‑year‑old female child involving half of the mandible, which was successfully treated with conservative therapy. This case report illustrates the effectiveness of simplified surgical treatment for a large dentigerous cyst in the mixed dentition period. Back

Aim: The subcutaneous fat in the lower abdomen (LA) is more resistant to resorption as compared to the upper abdomen (UA). Males and females have variability in fat deposition and resorption in the abdominal region. Hence, there could be a difference in morphology of fat cells of these regions.... Read more

Aim: The subcutaneous fat in the lower abdomen (LA) is more resistant to resorption as compared to the upper abdomen (UA). Males and females have variability in fat deposition and resorption in the abdominal region. Hence, there could be a difference in morphology of fat cells of these regions. The present study aims to identify the differences in morphology of subcutaneous fat lobules of upper and LA. Methods: Subcutaneous fat samples were collected from upper and LA of 40 cadavers (33 males and 7 females). The shape, the arrangement, and the color of superficial and deep subcutaneous fat lobules were observed. The height and width were recorded for larger fat lobules. Results: There was a difference in the color, shape, size, and arrangement of the fat lobules between the two locations. Height (P = 0.042) and width (P = 0.008) of deep subcutaneous fat of LA were significantly larger than the UA in males while the height of superficial fat (P = 0.016) was significantly larger in LA than the UA in females. Height of the deep fat of UA (P = 0.018) and width of deep fat of the LA (P = 0.020) were significantly larger in females as compared to males. Conclusion: There was a significant difference in the morphology of the superficial and deep subcutaneous fat based on location and gender of the patient. Back

Ectrodactyly-ectodermic dysplasia-cleft lip/palate (EEC) syndrome is a rare congenital anomaly of inherited origin and varying clinical features. This syndrome has three main symptoms, which display variable expression and penetrance. The management of this syndrome is challenging, with few... Read more

Ectrodactyly-ectodermic dysplasia-cleft lip/palate (EEC) syndrome is a rare congenital anomaly of inherited origin and varying clinical features. This syndrome has three main symptoms, which display variable expression and penetrance. The management of this syndrome is challenging, with few reports in the medical literature. We present a case of a 22-year-old boy with EEC syndrome and offer insight into current knowledge about this syndrome. Back

Vascularized composite allotransplantation (VCA) has emerged as a viable treatment option for limb and face reconstruction of severe tissue defects. Functional recovery after VCA requires not only effective immunosuppression, but also consideration of peripheral nerve regeneration to facilitate... Read more

Vascularized composite allotransplantation (VCA) has emerged as a viable treatment option for limb and face reconstruction of severe tissue defects. Functional recovery after VCA requires not only effective immunosuppression, but also consideration of peripheral nerve regeneration to facilitate motor and sensory reinnervation of donor tissue. At the time of transplantation, the donor and recipient nerves are typically coapted in an end‑to‑end fashion. Following transplantation, there are no therapies available to enhance nerve regeneration and graft reinnervation, and functional outcomes are dependent on the recipients’ innate regenerative capacities. Functional outcomes to date have been promising, but there is still much room for improvement, studies have demonstrated reliable return of protective sensation (pain, thermal, gross tactile), while discriminative sensation and motor function show more inconsistent results. In order to maximize the benefit afforded to the by VCA, we must develop consistent and reliable procedures and therapies to ensure effective nerve regeneration and functional outcomes. New technologies, such as nerve guidance conduits and fibrin glues, and the use of stem cells to facilitate nerve regeneration remain untested in VCA but are proving worthwhile in the context of peripheral nerve repair. VCA presents a unique set of challenges with regards to surgical techniques, postoperative regimen, and health of donor tissue. In this review, we discuss current challenges underlying achievement of nerve regeneration in VCA and discuss novel technologies and approaches to translate nerve regeneration into functional restoration. Back

Microsurgery comprises a variety of surgical procedures such as neurovascular anastomoses, performed under optical magnification and with fine instrumentation. While refinements have been made since its advent in the 1960s, robotics offers the potential for major technological advancement.... Read more

Microsurgery comprises a variety of surgical procedures such as neurovascular anastomoses, performed under optical magnification and with fine instrumentation. While refinements have been made since its advent in the 1960s, robotics offers the potential for major technological advancement. Endoscopic telemicrosurgery is minimally invasive, robotically-assisted microsurgery. This technique removes some limitations of conventional microsurgery and enhances visual and manual dexterity. Vision is enhanced through greater magnification, three‑dimensionality, and functionalization, all through an endoscopic view. Manual dexterity is improved by suppression of physiological tremor and tremor filtration, while permitting useful enhancement of movement amplitudes and tactile feedback forces. Furthermore, better endoscopic ergonomics, new hand tools and the ability for multi‑manual and remote work, confer a distinct advantage. Endoscopic telemicrosurgery is already in clinical use. Some of the advantages above are incorporated into the DaVinci® robot, that is, used in brachial plexus surgery. Conventional brachial plexus surgery requires large incisions for exploration and neurotization, with its attending risks of unsightly scars, prolonged hospital stay, sepsis, and perineural adhesions that interfere with nerve regrowth. Endoscopic telemicrosurgery limits the incisions and these risks, with minimal compromise. Endoscopic telemicrosurgery, through the amplification of human capabilities may pave the way for a major advancement in the microsurgical field. Back

Traumatic injuries resulting in peripheral nerve lesions lead to important morbidity with devastating social and economic consequences. When the lesioned nerve cannot be sutured directly, a nerve graft is generally required to bridge the gap. Although autologous nerve grafting is still the first... Read more

Traumatic injuries resulting in peripheral nerve lesions lead to important morbidity with devastating social and economic consequences. When the lesioned nerve cannot be sutured directly, a nerve graft is generally required to bridge the gap. Although autologous nerve grafting is still the first choice for reconstruction, it has the severe disadvantage of the sacrifice of a functional nerve. Research in tissue engineering and nerve regeneration may have a dramatic impact on clinical and surgical treatment of such nerve lesions. The authors review the latest concepts in tissue engineering for nerve repair, including scaffold engineering of neural guides, biomaterial modification, cell therapy, growth factors delivery, and electrical stimulation. Recent literature is reviewed in detail, pointing out the most interesting present achievements and perspectives for future clinical translation. Electronic search of the literature was performed using MEDLINE, Embase, and the Cochrane Library to identify research studies on peripheral nerve regeneration through tissue‑engineered conduits. The following medical subject headings were used to carry out a systematic search of the literature: “nerve regeneration”, “stem cells”, “biomaterial”, “extracellular matrix”, “functional regeneration”, “growth factors” and “microchannels”. Included literature was published between 1991 and 2014. The reference lists from the retrieved articles were also reviewed for additional articles. In total, 76 articles were included in this study. Back

One of the most important goals in treating proximal nerve injuries is to maintain the function of distal effectors during axonal regeneration. “Babysitting”, that is, connecting the injured nerve to a healthy trunk provides a bypass for distal neural regeneration or reactivation. It avoids... Read more

One of the most important goals in treating proximal nerve injuries is to maintain the function of distal effectors during axonal regeneration. “Babysitting”, that is, connecting the injured nerve to a healthy trunk provides a bypass for distal neural regeneration or reactivation. It avoids degeneration of sensory and motor terminations, with minimal donor nerve damage. We present a technique where a nerve graft is used between ulnar and median nerve through two end‑to‑side sutures in the distal third of the forearm, in two different cases of proximal ulnar nerve injury. Both patients were young manual workers, the former suffered a total nerve disruption proximal to the elbow following a car accident and the latter suffered a perineurial scar from a high voltage injury at the proximal third of the forearm. The proximal injury was grafted with a sural nerve in the former and treated by neurolysis in the latter. Results were graded by the Highet‑Zachary scale for both sensory and motor recovery. The outcomes of our series were compared to six other case reports in the literature (including median nerves) treated with this technique. Both clinical and experimental data show that babysitting effectively protects distal effectors. Back

Proximal nerve injury can lead to devastating functional impairment. Because axonal regeneration is slow, timely reinnervation of denervated muscle does not occur. These denervated muscles atrophy and lose function. Sensory protection is a surgical technique thought to prevent denervated muscle... Read more

Proximal nerve injury can lead to devastating functional impairment. Because axonal regeneration is slow, timely reinnervation of denervated muscle does not occur. These denervated muscles atrophy and lose function. Sensory protection is a surgical technique thought to prevent denervated muscle impairment using local sensory nerves to provide trophic support to the muscle until motor nerves can regenerate, and neuromuscular junctions are reestablished. We performed a comprehensive literature search using multiple databases to find primary articles reporting on the outcomes and treatment of sensory protection. This paper reviews the three main approaches to sensory protection: (1) end‑to‑end neurorrhaphy, (2) end‑to‑side neurorrhaphy, and (3) direct muscle neurotization. It discusses the evidence supporting each technique and outlines goals for future investigations. Back

Nerve transfer surgery, also referred to neurotization, developed in the mid 1800s with the use of animal models, and was later applied in the treatment of brachial plexus injuries. Neurotization is based on the concept that following a proximal nerve lesion with a poor prognosis, expendable... Read more

Nerve transfer surgery, also referred to neurotization, developed in the mid 1800s with the use of animal models, and was later applied in the treatment of brachial plexus injuries. Neurotization is based on the concept that following a proximal nerve lesion with a poor prognosis, expendable motor or sensory nerves can be re-directed in proximity of a specific target, whether a muscle or skin territory, in order to obtain faster re-innervation. Thanks to the contribution of several authors including Oberlin, MacKinnon and many others, the field of nerve transfer surgery has expanded in treatment of not only the brachial plexus, but also the arm, forearm and hand. This article reviews the recent literature regarding current concepts in nerve transfer surgery, including similarities to and differences from tendon transfer surgery. Moreover, indications and surgical techniques are illustrated for different types of nerve injury affecting the extrinsic and intrinsic musculature of the hand as well as sensory function. Back

The aim of this review is to extrapolate evidence regarding the use of vascularized nerve grafts (VNGs) in peripheral nerve reconstruction and summarize available data on their indications, if any, and clinical applications. A review of the literature via the PubMed database was performed with... Read more

The aim of this review is to extrapolate evidence regarding the use of vascularized nerve grafts (VNGs) in peripheral nerve reconstruction and summarize available data on their indications, if any, and clinical applications. A review of the literature via the PubMed database was performed with analysis of ninety-five articles on the experimental and clinical studies of VNGs. Eight relevant questions were selected to be answered about VNGs. VNGs allow faster nerve regeneration and convey a functional advantage under certain clinical conditions such as large nerves, proximal lesions, and nonvascularized recipient beds. Several donor sites are available which have been being divided by body region in this manuscript. VNGs perform better than non‑VNGs and provide an advantage in selected cases. However, limited availability and donor site morbidity still limit their application. We foresee a wider application of vascularized nerve allografts to overcome these problems. Back

Ulnar nerve neuropathy at the elbow represents the second most frequent compression neuropathy of the upper extremity. Of the five different anatomical areas responsible for ulnar nerve compression at the elbow region, the epitrochlear-olecranon channel and Osborne’s arcade are the most common.... Read more

Ulnar nerve neuropathy at the elbow represents the second most frequent compression neuropathy of the upper extremity. Of the five different anatomical areas responsible for ulnar nerve compression at the elbow region, the epitrochlear-olecranon channel and Osborne’s arcade are the most common. An additional cause of nerve damage is a dynamic process in which the ulnar nerve dislocates anteriorly at the epitrochlear-olecranon level during elbow flexion, partially or completely, causing nerve friction and constriction leading to chronic neuropathic pain. Failure after primary surgery is generally secondary to procedural errors or technical omissions, frequently represented by incomplete nerve decompression, failure to recognize nerve instability after nerve decompression, loosening of the nerve anchor after superficial nerve transposition with consequent spontaneous nerve relocation in the epitrochlear‑olecranon channel, perineural fibrosis and neurodesis, which creates new nerve compression. In association with the clinical evaluation, electromyography studies, magnetic resonance imaging and ultrasound are useful tools that may aid in the decision‑making process when considering revision surgery. Superficial anterior transposition is the most commonly employed technique but also has a high failure rate, as opposed to anterior deep transposition that is the method of choice for many surgeons despite being more technically demanding. The results of revision surgery following recalcitrant ulnar nerve compression at the elbow are inferior to those obtained after primary surgery. Nonetheless, the clinical advantages remain relevant provided that the revision surgery is performed by an expert surgeon. To avoid misinterpretation, the patient is completely informed of the quality of results. Back

Neuropathic pain is characterized by spontaneous and provoked pain and other signs reflecting neural damage. Aberrant regeneration following peripheral nerve lesions leaves neurons unusually sensitive and prone to spontaneous pathological activity, abnormal excitability and heightened sensitivity to stimuli. This review covers the current understanding of neuropathic pain after bilateral sagittal split osteotomy (BSSO) of the lower jaw. The reported incidence of neuropathic pain after mandibular osteotomies is less than 1%, while the incidence in patients with iatrogenic inferior alveolar nerve (IAN) injuries during BSSO can be as high as 45%. The factors which modulate the healing process toward neuropathic pain during or after nerve damage have not yet been elucidated. Patients at highest risk for developing post‑BSSO neuropathic pain are older than 45 years and have undergone procedures involving IAN compression, partial severance, or complete discontinuity of the lingual nerve with a proximal stump neuroma, patients with nerve injury repair delayed longer than 12 months and patients with chronic illnesses that compromise healing or increase risk for peripheral neuropathy. Although neuropathic pain tends to be long‑lasting, some patients can recover completely. Preventive measures include risk assessment prior to surgery, prevention of nerve damage during surgery, and early repair of nerve injury. Back

Neuropathic pain of the upper limb results from damage or disease of the upper limb somatosensory system caused by wide range of pathologies including peripheral neuromas. Treatment strategies depend on making an accurate diagnosis, recognizing co-existing pathologies, and formulating an... Read more

Neuropathic pain of the upper limb results from damage or disease of the upper limb somatosensory system caused by wide range of pathologies including peripheral neuromas. Treatment strategies depend on making an accurate diagnosis, recognizing co-existing pathologies, and formulating an individualized treatment plan that commonly involves multiple modalities. A long list of nonsurgical and surgical methods acting peripherally (neuromodulation, nerve blocks, surgical manipulation of the nerve) and centrally (medications, spinal cord, and deep brain stimulation) has been described and it is clear that no one treatment is wholly reliable. In this article, we briefly review the pathophysiology of pain caused by neuromas, the current treatment options and the latest research in therapeutic developments. Back

Nerve-tissue interactions are critical. Peripheral nerve injuries may involve intraneural and extraneural scar formation and affect nerve gliding planes, sometimes leading to complex clinical presentations. All of these pathological entities involve pain as the main clinical symptom and can be... Read more

Nerve-tissue interactions are critical. Peripheral nerve injuries may involve intraneural and extraneural scar formation and affect nerve gliding planes, sometimes leading to complex clinical presentations. All of these pathological entities involve pain as the main clinical symptom and can be subsumed under the term “painful scar neuropathy”. The authors review the literature on treatment approaches to peripheral nerve scar neuropathy and the outcomes of neurolysis‑associated procedures and propose a simple classification and a therapeutic approach to scar neuropathy. The search retrieved twenty-one papers, twenty of which reported pain reduction or resolution with various techniques. There is no consensus on the best therapeutic approach to neuropathic pain due to scar tethering. Most authors report good or excellent results with different techniques, from nerve wrapping with anti‑adhesion devices to nerve coverage or wrapping with vascularized tissue. The authors’ classification of and therapeutic approach to peripheral nerve scar lesions aims at promoting a logical approach based on the analysis of lesion type (perineural, or endoneural and perineural), pain type (due to traction or external trauma, pain at rest), and number of previous operations. Patients need to be informed that multiple procedures may be required, that outcomes may be partial, and that surgery can potentially worsen preoperative conditions. The review found no evidence for the best therapeutic approach to scar neuropathy, but there is consensus on a multidisciplinary approach. Back

Peripheral nerve injuries are a heterogeneous group of lesions that may occurs secondary to various causes. Several different classifications have been used to describe the pathophysiological mechanisms leading to the clinical deficit, from simple and reversible compression-induced demyelination,... Read more

Peripheral nerve injuries are a heterogeneous group of lesions that may occurs secondary to various causes. Several different classifications have been used to describe the pathophysiological mechanisms leading to the clinical deficit, from simple and reversible compression-induced demyelination, to complete transection of nerve axons. Neurophysiological data localize, quantify, and qualify (demyelination vs. axonal loss) the clinical and subclinical deficits. High-resolution ultrasound can demonstrate the morphological extent of nerve damage, fascicular echotexture (epineurium vs. perineurium, focal alteration of the cross-section of the nerve, any neuromas, etc.), and the surrounding tissues. High field magnetic resonance imaging provides high contrast neurography by fat suppression sequences and shows structural connectivity through the use of diffusion-weighted sequences. The aim of this review is to provide clinical guidelines for the diagnosis of nerve injuries, and the rationale for instrumental evaluation in the preoperative and postoperative periods. While history and clinical approach guide neurophysiological examination, nerve conduction and electromyography studies provide functional information on conduction slowing and denervation to assist in monitoring the onset of re‑innervation. High‑resolution nerve imaging complements neurophysiological data and allows direct visualization of the nerve injury while providing insight into its cause and facilitating surgical treatment planning. Indications and limits of each instrumental examination are discussed. Back

Aim: The purpose of the study is to present a management protocol for various types of soft tissue defects of the distal third region of leg and foot treated with pedicle flaps, by including hyperbaricoxygen (HBO) therapy in the treatment regimen with flap delay. Methods: We present a prospective... Read more

Aim: The purpose of the study is to present a management protocol for various types of soft tissue defects of the distal third region of leg and foot treated with pedicle flaps, by including hyperbaricoxygen (HBO) therapy in the treatment regimen with flap delay. Methods: We present a prospective study of 23 patients with various types of soft tissue defects of the foot, and lower third of leg managed in our institution from December 2012 to December 2013. All soft tissue defects were treated by a reverse pedicle flap. Twelve patients were managed with flap delay with HBO therapy and 11 patients with immediate flaps without HBO therapy. The postoperative period, hospital course, and follow‑up were documented. Results: Of 12 patients with flap delay and HBO, 10 patients did not suffer any complications secondary to flap transfer. One patient had discoloration of the tip of the flap, which settled without the intervention, and 1 patient had recurrent abscess formation, which required debridement and closure. Of 11 patients with direct transfer, 6 patients presented with complications including flap congestion, partial flap loss, and tip necrosis, which required secondary intervention. Conclusion: HBO therapy is a useful adjunct in flap delay of the reverse pedicle flap for soft tissue reconstruction of the lower third of the leg and foot regions. Back

Aim: To present a simple technical modification of a medial osteotomy cut which prevents its misdirection and overcomes various anatomical variations as well as technical problems. Methods: The medial osteotomy cut is modified in the posterior half at an angle of 15°‑20° following novel... Read more

Aim: To present a simple technical modification of a medial osteotomy cut which prevents its misdirection and overcomes various anatomical variations as well as technical problems. Methods: The medial osteotomy cut is modified in the posterior half at an angle of 15°‑20° following novel landmarks. Results: The proposed cut exclusively directs the splitting forces downwards to create a favorable lingual fracture, preventing the possibility of an upwards split which would cause a coronoid or condylar fracture. Conclusion: This modification has proven to be successful to date without encountering the complications of a bad split or nerve damage. Back

Aim: Augmentation mammoplasty is a commonly performed procedure with a high satisfaction rate. Multiplane pocket was described for simultaneous internal mastopexy and augmentation using inframammary crease incision for selected primary and secondary mammoplasties. The use of the technique is... Read more

Aim: Augmentation mammoplasty is a commonly performed procedure with a high satisfaction rate. Multiplane pocket was described for simultaneous internal mastopexy and augmentation using inframammary crease incision for selected primary and secondary mammoplasties. The use of the technique is presented with a larger experience for correction of ptosis in a patient presenting for revision surgery following subglandular augmentation mammoplasty. Methods: A retrospectively collected data were analyzed using the Excel Spread Sheet. A total of 25 patients had multiplane augmentation with the internal mastopexy following augmentation mammoplasty in subglandular pocket. Data of 25 patients who had their revision surgery in multiplane were analyzed. Results: The group included 25 patients with a mean age of 36.6 years (range: 25-54 years) with mean implant duration of 6.4 years (range: 1.5-13 years). Twenty‑three of the patients were nonsmokers, 1 smoker and 1 patient’s smoking status was not mentioned. Eighteen patients presented with grade I capsular contracture, 3 patients with grade II contracture and 4 patients had a combination of grade I and II capsular contracture. Pseudoptosis was present in 6, class B ptosis in 6, A/B ptosis in 3, water‑down deformity in 5 and rippling in 5 patients. Average preoperative size of implant used initially was 334.4 mL (range: 250‑340 mL) and the mean implant size selected for revision surgery was 416 mL (range: 260‑525 mL). Mean follow‑up time was 18 months (range: 6‑48 months). Of 25 patients, 21 had a bilateral procedure whereas the technique was used unilaterally in 4 patients for the correction of asymmetry. All patients had a single dose of intravenous antibiotics and followed by an oral course for 5 days, there was no infection noted in the series. In the current series, no patient required revision surgery following the multiplane internal mastopexy. Conclusion: Multiplane internal mastopexy can be useful in selected cases of revisionary augmentation mammoplasty. Back

Tensor fascia lata (TFL) flap is a versatile myofasciocutaneous flap. It has varied usages as both free and pedicled flap. As a pedicled flap, it is a good option for reconstructing soft tissue defects after tumor ablation. The TFL perforator flap is a good alternative for anterolateral thigh... Read more

Tensor fascia lata (TFL) flap is a versatile myofasciocutaneous flap. It has varied usages as both free and pedicled flap. As a pedicled flap, it is a good option for reconstructing soft tissue defects after tumor ablation. The TFL perforator flap is a good alternative for anterolateral thigh (ALT) flap. The advantages of TFL flap are that dissection can be made through the same incision, without impairment of other donor sites. The reconstructive plan remains same as that of ALT flap. TFL flap offers a good volume of skin and can be made thin removing variable portions of muscle. The present case is a 63‑year‑old patient with a carcinoma penis who underwent left ilioinguinal block dissection resulting in a defect of 8 cm × 8 cm in the left inguinal region. TFL flap was raised with U‑shaped incision and used for closure of the defect with good result. Back

Aim: Autologous fat grafting has gained acceptance as a technique to improve aesthetic outcomes in breast reconstruction. The purpose of this study was to share our clinical experience using autologous fat injection to correct contour deformities during breast reconstruction. Methods: A single... Read more

Aim: Autologous fat grafting has gained acceptance as a technique to improve aesthetic outcomes in breast reconstruction. The purpose of this study was to share our clinical experience using autologous fat injection to correct contour deformities during breast reconstruction. Methods: A single surgeon, prospectively maintained database of patients who underwent autologous fat injection during breast reconstruction from January 2008 to November 2013 at McGill University Health Center was reviewed. Patient characteristics, breast history, type of breast reconstruction, volume of fat injected, and complications were analyzed. Results: One hundred and twenty‑four patients benefited from autologous fat injection from January 2008 to November 2013, for a total of 187 treated breasts. The patients were on average 49.3 years old (± 8.9 years). Fat was harvested from the medial thighs (20.5%), flanks (39.1%), medial thighs and flanks (2.9%), trochanters (13.3%), medial knees (2.7%), and abdomen (21.9%). An average of 49.25 mL of fat was injected into each reconstructed breast. A total of 187 breasts in 124 patients were lipo‑infiltrated during the second stage of breast reconstruction. Thirteen breasts (in 12 separate patients) were injected several years after having undergone lumpectomy and radiotherapy. Of the 187 treated breasts, 118 were reconstructed with expanders to implants, 45 with deep inferior epigastric perforator flaps, 9 with latissimus dorsi flaps with implants, 4 with transverse rectus abdominis myocutaneous flaps, and 13 had previously undergone lumpectomy and radiotherapy. Six complications were noted in the entire series, for a rate of 3.2%. All were in previously radiated breasts. Average follow‑up time was 12 months (range: 2‑36 months). Conclusion: Fat injection continues to grow in popularity as an adjunct to breast reconstruction. Our experience demonstrates a low complication rate as compared to most surgical interventions of the breast and further supports its safety in breast reconstruction. However, caution should be used when treating previously radiated breasts. Back

What could be better than improving the comfort and quality of life of a patient with a life-threatening disease? Maxillectomy, the partial or total removal of the maxilla in patients suffering from benign or malignant neoplasms, creates a challenging defect for the maxillofacial prosthodontist... Read more

What could be better than improving the comfort and quality of life of a patient with a life-threatening disease? Maxillectomy, the partial or total removal of the maxilla in patients suffering from benign or malignant neoplasms, creates a challenging defect for the maxillofacial prosthodontist when attempting to provide an effective obturator. Although previous methods have been described for rehabilitation of such patients, our goal should be to devise one stage techniques that will allow the patient an improved quality of life as soon as possible. The present report describes the aesthetic rehabilitation of a maxillectomy patient by use of a hollow obturator. The obturator is fabricated through a processing technique which is a variation of other well‑known techniques, consisting of the use of a single‑step flasking procedure to fabricate a single‑unit hollow obturator using the lost salt technique. As our aim is to aesthetically and functionally rehabilitate the patient as soon as possible, the present method of restoring the maxillectomy defect is cost‑effective, time‑saving and beneficial for the patient. Back

Hemifacial microsomia and Goldenhar syndrome pose unique challenges to the craniofacial surgeon. The O.M.E.N.S. classification provides a description of the craniofacial features. For the “M” of O.M.E.N.S. (the mandible), the Pruzansky-Kaban classification provides therapeutic guidelines for... Read more

Hemifacial microsomia and Goldenhar syndrome pose unique challenges to the craniofacial surgeon. The O.M.E.N.S. classification provides a description of the craniofacial features. For the “M” of O.M.E.N.S. (the mandible), the Pruzansky-Kaban classification provides therapeutic guidelines for joint and face reconstruction. A sequence of standard procedures, including temporomandibular joint reconstruction, facial rotation surgery, gluteal fat grafting, and patient-specific titanium implantation, each have their intricacies. The author provides his expert opinion, acquired over thirty years of experience, with an emphasis on descriptions of and solutions for ten problematic issues. Back

Pain during extraction of impacted mandibular third molars which can occur despite adequate local anesthesia is termed as “escape pain phenomenon”. Recently, it was described during elevation of a mesioangular impacted mandibular third molar and also while curetting an extracted third molar... Read more

Pain during extraction of impacted mandibular third molars which can occur despite adequate local anesthesia is termed as “escape pain phenomenon”. Recently, it was described during elevation of a mesioangular impacted mandibular third molar and also while curetting an extracted third molar socket. This phenomenon has been overlooked, as it was previously considered secondary to pressure effect on the inferior alveolar neurovascular bundle (IANB). However, it is unlikely that the pain impulses originate from direct pressure on the IANB, as the nerve is blocked more proximally at its entry into the mandible. The authors speculated that the occasional presence of a neurovascular plexus (NVP) independent of the IANB causes the escape of a pain impulse upon stimulation by root pressure or instrumentation. To validate the presence of such a plexus, a meticulous literature search and review were performed. The search revealed evidence of the occasional presence of a NVP consisting of auriculotemporal and/or retromolar neural filaments. The plexus may be present around the inferior alveolar artery or embedded within the IANB, and does not innervate the tooth. This plexus likely propagates pain impulses only upon stimulation by compression or instrumentation in the apical area of the tooth socket. This theory explains the absence of pain during tooth sectioning and bone guttering in the presence of a complete inferior alveolar nerve block. Back

Aim: Heparin is a multifaceted compound with uses not only as an anticoagulant, but also as an anti-inflammatory, anti-allergenic, anti-histaminic, anti-serotonin, anti-proteolytic and neoangiogenic agent. The aim of the study was to study the effect of topical heparin in the management of... Read more

Aim: Heparin is a multifaceted compound with uses not only as an anticoagulant, but also as an anti-inflammatory, anti-allergenic, anti-histaminic, anti-serotonin, anti-proteolytic and neoangiogenic agent. The aim of the study was to study the effect of topical heparin in the management of second-degree burns. Methods: Between December 2005 and January 2007, 60 consecutive patients, aged 10-60 years, with first‑and second‑degree thermal injuries ranging from 10% to 60%, were randomly enrolled in the study divided into a control group (C) and a heparin group (H) of 30 patients each. Results: Patients treated with topical heparin experienced statistically significant improved pain relief, faster healing, fewer complications and shorter hospital stays. The majority of the patients admitted were in an economically productive age group and were predominantly female. The distribution between the two groups according to age, type of burns and extent of burns was not statistically different. Conclusion: The current study demonstrates the efficacy of topical heparin in the treatment of first‑ and second‑degree burns. Back

The flexor carpi radialis (FCR) is one of the long flexors, which is important in flexing and abducting the hand at the wrist. It originates at the medial epicondyle of the humerus and attaches at the base of the second metacarpal. Closed rupture of the long flexors of the finger is... Read more

The flexor carpi radialis (FCR) is one of the long flexors, which is important in flexing and abducting the hand at the wrist. It originates at the medial epicondyle of the humerus and attaches at the base of the second metacarpal. Closed rupture of the long flexors of the finger is well-described, especially in association with rheumatoid hands. However, rupture of the FCR is rare; only 11 cases reported in the literature, most of them associated with scaphotrapezial‑trapezoidal osteoarthritis. We describe 1 case of complete FCR rupture secondary to trauma, showing that long‑term disability following FCR rupture is minimal. Back

Congenital bilateral macrostomia is a very rare deformity of the mouth, and it is still rarer to see cases of isolated bilateral macrostomia. Although the creation of a symmetric neocommissure is imperative, this presents a technical challenge. A review of the literature for surgical solutions... Read more

Congenital bilateral macrostomia is a very rare deformity of the mouth, and it is still rarer to see cases of isolated bilateral macrostomia. Although the creation of a symmetric neocommissure is imperative, this presents a technical challenge. A review of the literature for surgical solutions revealed various techniques, but no cases in which a bilateral straight line repair was described and adopted. This report presents the case of a 3-month-old boy with isolated bilateral macrostomia for whom straight line closure was performed on both sides. At 1 year follow-up, the oral commissures are symmetric with aesthetically pleasing scars and no lateral migration. Back

Desmoplastic ameloblastoma (DA) is an unusual variant of ameloblastoma exhibiting important differences in the anatomical distribution, radiographic features and histologic appearance compared with the classic type of ameloblastoma. The purpose of this paper is to report a case of DA in the... Read more

Desmoplastic ameloblastoma (DA) is an unusual variant of ameloblastoma exhibiting important differences in the anatomical distribution, radiographic features and histologic appearance compared with the classic type of ameloblastoma. The purpose of this paper is to report a case of DA in the anterior left maxilla and to describe a simple method of reconstruction with the use of buccal fat pad (BFP). BFP is an excellent choice for reconstruction of small to medium sized defects. It should be manipulated gently and hemostasis should be achieved meticulously during this surgery. It should not be sutured under tension. Back

Pseudo-angiosarcomatous or pseudovascular squamous cell carcinoma (SCC) of the skin is an unusual variant form of acantholytic SCC that mimics the histopathological appearance of angiosarcoma. We describe a case of pseudovascular SCC in a 77-year-old lady to highlight the frequent recurrence and... Read more

Pseudo-angiosarcomatous or pseudovascular squamous cell carcinoma (SCC) of the skin is an unusual variant form of acantholytic SCC that mimics the histopathological appearance of angiosarcoma. We describe a case of pseudovascular SCC in a 77-year-old lady to highlight the frequent recurrence and aggressiveness, as well as the clinicopathological features of this rare form of cutaneous SCC, and demonstrate the difficulties in establishing the correct diagnosis. Plastic surgeons involved in the care of patients with cutaneous malignancies should be aware of this variant of SCC and its aggressive nature in order to manage these patients appropriately. Back

Tibial nerve injury is rare and is always associated with other injuries due to its close association with the other structures. We present a rare case of isolated injury to the tibial nerve where the nerve was avulsed from the middle third of the leg, but all other structures were intact. The... Read more

Tibial nerve injury is rare and is always associated with other injuries due to its close association with the other structures. We present a rare case of isolated injury to the tibial nerve where the nerve was avulsed from the middle third of the leg, but all other structures were intact. The nerve was reconstructed with sural nerve grafts. The patient recovered sensation of the sole 12 months following the reconstruction and was able to maintain a normal gait and is living normal life. The results of nerve repairs in lower limbs in general have been poor. The treatment options for such an interesting case are discussed along with the management and outcome of the presented patient. Back

Aim: Reconstruction of defects of the eyelids and malar region following trauma may result in considerable distortion of the adjacent tissue. A clinical study was undertaken to demonstrate the ability to utilize a modified McGregor flap for reliable soft tissue coverage. Methods: Nine patients... Read more

Aim: Reconstruction of defects of the eyelids and malar region following trauma may result in considerable distortion of the adjacent tissue. A clinical study was undertaken to demonstrate the ability to utilize a modified McGregor flap for reliable soft tissue coverage. Methods: Nine patients with eyelids and malar soft tissue defects were treated over a period of 12 months from July 2013 to June 2014. In this prospective study, a McGregor flap was used for the closure of defects in 9 patients (7 men and 2 women), aged 20-36 years (mean age: 27 years). Three sessions of hyperbaric oxygen therapy were administered postoperatively, and patients received subsequent follow-up. Results: Six patients presented with malar and lower eyelid defects, two patients presented with malar defects, and one patient with upper eyelid, lower eyelid and malar defects following trauma. A McGregor flap was performed in all patients. The preexcision defects varied in size from 3 cm × 2 cm to 4 cm × 3 cm. No secondary procedures were required in any case. Sutures were removed between 7 and 9 days postoperatively. There were no cases of partial or total flap loss over the course of 10-14 months follow-up. Conclusion: The outcome following use of the McGregor flap procedure was functionally and aesthetically satisfactory in all cases. The McGregor flap is a useful option for the reconstruction of defects following trauma to the upper eyelid, lower eyelid, and malar regions. Back

Explantation following aesthetic mammoplasty without implant replacement is quite uncommon and often leaves the patient worse off than prior to mammoplasty. A case is presented here in which patient's own tissue was used as an inferior dermoglandular flap for autologous breast remodeling.... Read more

Explantation following aesthetic mammoplasty without implant replacement is quite uncommon and often leaves the patient worse off than prior to mammoplasty. A case is presented here in which patient's own tissue was used as an inferior dermoglandular flap for autologous breast remodeling. Inferior dermal flap has been described for breast reconstruction and simultaneous augmentation mammoplasty with mastopexy for prosthesis cover in the lower pole of the breast, but its use following explantation without implant replacement has not been described for breast remodeling and volume conservation. Back

Aim: Autologous tissue is considered the "gold standard" for breast reconstruction today. However, little is known about deep inferior epigastric perforator (DIEP) flap reconstruction in combination with tissue expander (TE)/implant. The authors describe a series of combined DIEP flap/TE... Read more

Aim: Autologous tissue is considered the "gold standard" for breast reconstruction today. However, little is known about deep inferior epigastric perforator (DIEP) flap reconstruction in combination with tissue expander (TE)/implant. The authors describe a series of combined DIEP flap/TE reconstruction, including its indications and technique to ensure protection of the pedicle during the expansion process. Methods: Between January 2009 and December 2012, patients undergoing immediate DIEP with TE reconstruction were retrospectively reviewed. Oncologic, comorbid conditions, intraoperative, postoperative expansion, complications, and technique data points were collected. Photographs were taken postoperatively and patient's satisfaction surveys were obtained to assess overall satisfaction. Results: Five patients underwent immediate DIEP flap/TE reconstruction utilizing our alloderm sling technique. There were no complications to the pedicle, flap, expander, or mastectomy skin perioperatively or postoperatively. All patients describe being very satisfied, often with improved breast volume and projection as compared to their preoperative appearance. Conclusion: The results of this study suggest that DIEP flap/TE reconstruction is safe, in particular when utilizing the alloderm sling technique, and should be considered in patients who lack sufficient abdominal tissue, have existing breast asymmetries, or do not desire the scar deformity of latissimus dorsi. Back

It is fairly common to find anatomic variations and anomalies in the arterial pattern of the upper extremities. However, a complete absence of the distal ulnar artery bilaterally is extremely rare. During preoperative assessment for a radial forearm free flap, we accidentally discovered bilateral... Read more

It is fairly common to find anatomic variations and anomalies in the arterial pattern of the upper extremities. However, a complete absence of the distal ulnar artery bilaterally is extremely rare. During preoperative assessment for a radial forearm free flap, we accidentally discovered bilateral distal ulnar artery agenesis. In this article, the clinical implications of this variation are discussed, along with a review of the literature. Back

Aim: Crush injuries of the foot are often associated with partial or complete degloving of the heel pad. The purpose of this study is to present an algorithm for the management of various types of heel pad avulsion injuries, including hyperbaric oxygen (HBO) therapy in the treatment regimen.... Read more

Aim: Crush injuries of the foot are often associated with partial or complete degloving of the heel pad. The purpose of this study is to present an algorithm for the management of various types of heel pad avulsion injuries, including hyperbaric oxygen (HBO) therapy in the treatment regimen. Methods: We present a prospective study of 27 patients with various types of heel pad avulsion managed in our institution from December 2012 to June 2013. Heel pad avulsion injuries were classified according to the angiosomal pattern. Partial or complete avulsions were classified and treated accordingly. HBO therapy was administered postoperatively. The postoperative period, hospital course, and follow-up were documented in patients with heel pad avulsion injuries. Results: Of 27 patients, 20 cases presented with partial avulsion and 7 cases were complete avulsion. Of 20 cases of partial avulsion, one of the flaps was anchored with K-wire. Nineteen cases of partial heel pad avulsion were managed by suturing. Eight patients out of 20 required skin grafting as a secondary procedure at a later date. Out of 7 cases of complete avulsion, one was managed by full-thickness skin grafting, one case by reverse sural artery flap coverage, and four cases were managed by free tissue transfer. No flap revisions were required, and no complications were experienced for the transferred flaps. Conclusion: HBO therapy may be a useful adjunct in the treatment of heel pad avulsion injuries. Back

Preservation of the skin envelope and the inframammary fold is the main factor in achieving breast symmetry in unilateral reconstruction. Skin sparing mastectomy (SSM) type-IV followed by immediate autologous reconstruction and contralateral symmetrization permits realizing this goal in large,... Read more

Preservation of the skin envelope and the inframammary fold is the main factor in achieving breast symmetry in unilateral reconstruction. Skin sparing mastectomy (SSM) type-IV followed by immediate autologous reconstruction and contralateral symmetrization permits realizing this goal in large, ptotic breasted patients, and tumor superficially located in the inferior quadrants. If the tumor is superficially located in the superior or inferior quadrants with a previous lumpectomy or quadrantectomy scar in the superior quadrants, modified radical mastectomy and a staged procedure are recommended to avoid poor cosmetic results. Two patients who underwent immediate autologous reconstruction following SSM type-V with contralateral symmetrization in a one-stage procedure are presented. Back

Critical relationships between collagen and synovium exist and affect the function of the hand. Understanding these relationships enhances the ability to perform surgery including procedures addressing soft tissue and joint pathology. We present a series of surgical procedures based on this... Read more

Critical relationships between collagen and synovium exist and affect the function of the hand. Understanding these relationships enhances the ability to perform surgery including procedures addressing soft tissue and joint pathology. We present a series of surgical procedures based on this principle. Back

Aim: This study was conducted to determine the preferred analgesic and anti-inflammatory drugs prescribed by oral implantologists in India. Methods: A structured questionnaire was distributed to 332 dentists to gather information regarding their prescription habits for analgesics and... Read more

Aim: This study was conducted to determine the preferred analgesic and anti-inflammatory drugs prescribed by oral implantologists in India. Methods: A structured questionnaire was distributed to 332 dentists to gather information regarding their prescription habits for analgesics and anti-inflammatory drugs. Frequency distributions were computed by type of drug being prescribed and the protocol followed. Results: Analysis of data showed that majority of dentists (85.8%, n = 285) prescribed conventional non-steroidal anti-inflammatory drugs (NSAIDs) for implant surgery. The most common prescription was ibuprofen with paracetamol combination (32.2%, n = 107) followed by diclofenac (20.2%, n = 67). Most dentists reported prescribing different NSAIDs for the same procedure in different patients (64.7%, n = 215). Only, 35.5% (n = 118) followed the peri-operative protocol. Adjunctive prescription of steroids was done by only 33.7% (n = 112). Conclusion: Our study illustrates that the general trend of analgesic and anti-inflammatory drug prescription for dental implant surgery among Indian dentists is mostly in accordance with the guidelines for pain management worldwide. However, it is noteworthy that a few dentists do prescribe drugs not primarily indicated for dental pain management and use widely varying protocols for the same. Therefore, in order to avoid potential complications, it is essential to raise awareness of among the dental practitioners of the appropriate indications and dosage regimen of specific drugs. Back

The incidence of aneurysmal bone cyst in the maxillofacial region is rare and may remain undiagnosed for a long period prior to becoming symptomatic. This may cause associated issues secondary to compression by extending to the surrounding vital anatomical areas. An aggressive course can lead to... Read more

The incidence of aneurysmal bone cyst in the maxillofacial region is rare and may remain undiagnosed for a long period prior to becoming symptomatic. This may cause associated issues secondary to compression by extending to the surrounding vital anatomical areas. An aggressive course can lead to bony destruction with intracranial extension. We present a case of a 23-year-old man who presented with bilateral exorbitism with nasal obstruction. Back

Aim: To report the author's experience in augmentation phalloplasty by studying a retrospective series of patients who underwent fat grafting for girth enhancement or a composite technique based on suspensory ligament release plus fat grafting performed simultaneously. Methods: The author... Read more

Aim: To report the author's experience in augmentation phalloplasty by studying a retrospective series of patients who underwent fat grafting for girth enhancement or a composite technique based on suspensory ligament release plus fat grafting performed simultaneously. Methods: The author analyzed retrospectively the outcomes of 275 augmentation phalloplasty procedures performed in 259 patients until November 2013. Of these, 127 correspond to girth augmentation with fat grafting and 148 to composite augmentation phalloplasty (girth augmentation with fat grafting and length improvement by suspensory ligament release). In 16 patients girth and length enhancement were performed in two separate procedures. Results: Of this 259 patients, 87 underwent postoperative follow-up for at least 12 months and 160 patients underwent follow-up for at least 6 months. The average increase in circumference at 6 months was 1.7 cm (1.57 cm at 12 months) and the average increase in length of 3.2 cm (3.1 cm at 12 months). Twenty-two patients showed minor complications that were treated without sequelae and without influencing the final result. Conclusion: By judicious use of currently available techniques, it is possible to achieve stable increases in penis size. The use of composite techniques provides better final results than the use of individual techniques performed alone due to the increase of the actual volume of the penis. An adequate informed consent is essential in all patients due to the unrealistic expectations expressed by the majority of them. Back

Aim: Skin grafting is a common clinical practice for plastic surgeons, yet primary contraction of these grafts is a neglected topic. This study was designed to investigate primary contraction and introduce the shape of skin graft as a possible factor that modifies primary contraction behavior,... Read more

Aim: Skin grafting is a common clinical practice for plastic surgeons, yet primary contraction of these grafts is a neglected topic. This study was designed to investigate primary contraction and introduce the shape of skin graft as a possible factor that modifies primary contraction behavior, using porcine models. Methods: In the first series, full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) were compared. In a second series, how the shape of the skin graft affected the degree of contraction was examined. Results: The mean percentage of FTSG shrinkage was 12.04%, and the median was 12.18%. The mean percentage of STSG shrinkage was 6.87%, and the median was 5%. Circle-shaped and square-shaped FTSGs showed mean/median graft shrinkage of 5.83%/6.93% and 4.15%/3.75%, respectively. In STSGs, the circle-shaped and square-shaped grafts had mean/median graft shrinkage of 1.07%/0% and 0.31%/0%, respectively. Conclusion: Our preliminary report revealed an expected greater shrinkage of FTSGs compared with STSGs. Furthermore, in a limited number of specimens, the shape of the skin graft seemed to affect the primary contraction of the STSGs. Back

Severe crushing injuries to the distal forearm can preclude immediate hand replantation, with temporary ectopic implantation as a practicable option under special circumstances. This report describes a case of temporary ectopic hand implantation for a crush injury extending from the wrist to the... Read more

Severe crushing injuries to the distal forearm can preclude immediate hand replantation, with temporary ectopic implantation as a practicable option under special circumstances. This report describes a case of temporary ectopic hand implantation for a crush injury extending from the wrist to the middle third of the forearm, using the left foot as the recipient site. The hand was replanted onto the left forearm 3 months after the ectopic implantation, with functional gains seen by 18 months. Satisfactory ambulation was retained, with no reported foot pain. Temporary ectopic implantation is a pragmatic alternative under select circumstances. Back

Aim: While skin-sparing mastectomy (SSM) can be performed in patients with stage II-III breast cancer, the impact of neoadjuvant chemotherapy (NAC) on SSM rates and reconstructive modalities in these patients is not known. Methods: Between January 2007 and December 2009, 409 immediate breast... Read more

Aim: While skin-sparing mastectomy (SSM) can be performed in patients with stage II-III breast cancer, the impact of neoadjuvant chemotherapy (NAC) on SSM rates and reconstructive modalities in these patients is not known. Methods: Between January 2007 and December 2009, 409 immediate breast reconstructions (IBRs) were performed in patients with Stage II-III breast cancer. Data were collected on preoperative, operative, and postoperative factors. Results: There was a statistically significant relationship between clinical stage of disease and the utilization of SSM or non-SSM (P<0.0001). Seventy-five percent of all patients with stage II disease and 50% of patients with stage III disease underwent SSM; similarly, 75.5% of patients with stage II and 49.1% of patients with stage III disease who received NAC underwent SSM with immediate reconstruction, in spite of having a greater proportion of stage III patients (P<0.01). In addition, patients who received NAC followed by SSM with IBR had larger tumors (mean, 3.5 cm vs. 3.1 cm, P<0.001). The type of IBR, and size of skin defect was significantly affected by whether the patient underwent SSM or non-SSM (P=0.001, P<0.01, respectively). Conclusion: We are increasingly considering NAC to be an important tool to potentially reduce the morbidity of mastectomy, including the need to resect breast skin, which can subsequently enhance reconstructive outcomes in patients with clinical stage II and III breast cancer. Specifically, our data suggest that NAC patients with stage II and III breast cancer and larger tumors can reliably and safely undergo SSM in nearly half of cases, thus improving reconstructive outcomes and patient well-being. Back

Acne keloidalis nuchae (AKN) is a disease of unclear etiology that mainly affects males. Medical treatment of AKN is difficult, with refractory cases often requiring ablation by laser or surgical resection. We report herein, a 23-year-old male with refractory AKN treated successfully with... Read more

Acne keloidalis nuchae (AKN) is a disease of unclear etiology that mainly affects males. Medical treatment of AKN is difficult, with refractory cases often requiring ablation by laser or surgical resection. We report herein, a 23-year-old male with refractory AKN treated successfully with combined laser ablation, using an 810-nm diode laser and a 1064-nm Nd:YAG laser. Back

Aim: Incobotulinumtoxin A (xeomin) has been proposed as an alternative to abobotulinumtoxin A (dysport) and onabotulinumtoxin A (Botox) in the treatment of glabellar frown lines. A recent study is comparing abobotulinumtoxin A and onabotulinumtoxin A revealed equivalent efficacy with a dose... Read more

Aim: Incobotulinumtoxin A (xeomin) has been proposed as an alternative to abobotulinumtoxin A (dysport) and onabotulinumtoxin A (Botox) in the treatment of glabellar frown lines. A recent study is comparing abobotulinumtoxin A and onabotulinumtoxin A revealed equivalent efficacy with a dose conversion ratio of 2.5:1. We sought to establish effectiveness and dosing equivalency of incobotulinumtoxin A vs. abobotulinumtoxin A. Methods: Inclusion criteria for this pilot study included patients of a single surgeon (LAC) who had previously received a constant dose of abobotulinumtoxin A over at least four consecutive treatment sessions for the previous 12 months to achieve an 85-90% elimination of dynamic glabellar frown lines. The primary outcome sought dose comparison between established maintenance abobotulinumtoxin A dosing and incobotulinumtoxin A first-time dosing. A 2:1 conversion (abobotulinumtoxin A: incobotulinumtoxin A) was chosen in most patients. Secondary outcomes were patient-reported onset of effect, physician-assessed effect at 10-12 weeks, pain associated with administration, and patient perceived need for re-treatment at 2 weeks. Results: A total of 32 subjects were included. The mean dose of incobotulinumtoxin A was 17.1 units (± 6.1, the median dose 20 units). The mean dose of abobotulinumtoxin A was 27.6 (± 11.7, the median dose 27.5 units). The mean difference in treatment units was -10.5 (95% confidence interval, P < 0.001). Among 30 patients who reported effect onset, the median was 8.5 days, with a range of 1-14. At 10-12 weeks, muscle paralysis was assessed to be 69.2% (± 27.3), vs. 90.3% (± 1.8) with abobotulinumtoxin A (P < 0.001). The majority of patients rated pain of administration as equal or greater to that of abobotulinumtoxin A (63% and 22%, respectively). Three patients (9%) required re-treatment at 2 weeks with abobotulinumtoxin A due to lack of effective treatment with incobotulinumtoxin A. Abobotulinumtoxin A re-treatment was chosen by the patient. Conclusion: We found incobotulinumtoxin A at 17.1 (± 6.1) units to be less effective than abobotulinumtoxin A at 27.6 (± 11.7) units in the treatment of glabellar frown lines at 10-12 weeks postadministration. Dosing was less predictable than dosing associated with abobotulinumtoxin A treatment. Larger, randomized controlled trials are indicated to further delineate these differences and to clarify whether this difference from previously published incobotulinumtoxin A dosing may have been due to the small sample size. Back

Although major contributions have been made in the field of reconstructive surgery, reconstructive surgery of the auricle is a daunting prospect even for the most experienced surgeons. Here, we present a case who presented to us in the emergency surgical ward with a history of an accidental... Read more

Although major contributions have been made in the field of reconstructive surgery, reconstructive surgery of the auricle is a daunting prospect even for the most experienced surgeons. Here, we present a case who presented to us in the emergency surgical ward with a history of an accidental laceration of right ear. Primary repair of the ear laceration after wedge resection of the avulsed part was done. The cosmesis achieved by this technique is discussed. Back

The purpose of this systematic literature review was to evaluate the safety of liposuction techniques and to identify the cosmetic and noncosmetic application of liposuction. Liposuction can be used to improve the quality-of-life in patients with disabling medical conditions in addition to its... Read more

The purpose of this systematic literature review was to evaluate the safety of liposuction techniques and to identify the cosmetic and noncosmetic application of liposuction. Liposuction can be used to improve the quality-of-life in patients with disabling medical conditions in addition to its use for cosmetic rejuvenation. An online search of the Cochrane Library, MEDLINE, Embase, and SciELO were conducted. Forty-seven original articles reported from 1982 to February 2014 were included in this review. The articles reported on the use as well as the limitations of liposuction for treatment of noncosmetic and disabling medical conditions. The criteria used for selection of articles were: large sample size and originality. The case reports were excluded. There was a broad agreement about the applicability and the efficacy of the liposuction for treatment of these chronic medical conditions, such as multiple systemic lipomatosis, dercum's disease, chronic lymphedema, and axillary hyperhidrosis. Literatures review confirmed that Liposuction technique has provided significant and stable cure for these chronic medical conditions. Liposuction is the most frequent esthetic procedure for adipose tissue reduction and treatment of lipedema worldwide. Apart from esthetic indications, liposuction can also be used to treat chronic medical diseases and noncosmetic conditions. Back

Aim: Cranioplasty implants are used primarily in cases of surgical cranial decompression following pathological elevations of intracranial pressure. Available bone substitutes include porous hydroxyapatite (HA) and polymethylmethacrylate. Whichever material is used, however, prosthetic cranial... Read more

Aim: Cranioplasty implants are used primarily in cases of surgical cranial decompression following pathological elevations of intracranial pressure. Available bone substitutes include porous hydroxyapatite (HA) and polymethylmethacrylate. Whichever material is used, however, prosthetic cranial implants are susceptible to intra- and postsurgical complications and even failure. The aim of this study was to investigate such occurrences in HA cranioplasty implants, seeking not only to determine the likely causes (whether correlated or not with the device itself) but also, where possible, to suggest countermeasures. Methods: We analyzed information regarding failures or complications reported in postmarketing surveillance and clinical studies of patients treated worldwide with custom-made HA cranial implants (Custom Bone Service Fin-Ceramica Faenza, Italy) in the period 1997-2013. Results: The two most common complications were implant fractures (84 cases, 2.9% of the total fitted) and infections (51 cases, 1.77%). Conclusion: Although cranioplasties are superficial and not difficult types of surgery, and use of custom-made implants are often considered the "easy" option from a surgical perspective, these procedures are nonetheless plagued by potential pitfalls. If performed well they yield more than satisfactory results from the points of view of both the patient and surgeon, but lack of appropriate care can open the door to numerous potential sources of failure, which can compromise-even irreparably-the ability to heal. Back

Due to the complex three-dimensional structure of the nose, the repair of the nasal defect requires reconstruction of three different layers: skin envelope, osteocartilaginous framework and nasal lining. Before nasal reconstruction can be accomplished, the nose must rest on a stable platform to... Read more

Due to the complex three-dimensional structure of the nose, the repair of the nasal defect requires reconstruction of three different layers: skin envelope, osteocartilaginous framework and nasal lining. Before nasal reconstruction can be accomplished, the nose must rest on a stable platform to avoid late nasal obstructions, and septal deviations resulting from scar contraction. We present three cases of nasal reconstruction using a forehead flap in which we performed a preliminary stage to increase reliability of outcomes. Back